Presented by Jennifer Spring RD LDN Oncology Dietitian Learning Objectives Explain cancerrelated anorexia and the significance of unintentional weight loss Describe the evidence for specific nutritional interventions for patients experiencing anorexia and unintentional weight loss ID: 1040927
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10. Nutrition in Cancer Patients Makes a DifferencePresented by Jennifer Spring, RD, LDN, Oncology Dietitian
11. Learning ObjectivesExplain cancer-related anorexia and the significance of unintentional weight lossDescribe the evidence for specific nutritional interventions for patients experiencing anorexia and unintentional weight lossIdentify proper assessment tools for identifying indicators of malnutrition risk and appropriate nutritional interventions
12. Unintended weight loss and anorexia in patients with cancer are associated with decreased performance status, reduced response and tolerance to treatment, decreased survival, and reduced quality of life.
13. Anorexia Defined“Loss of appetite and inability to eat”“A lack or loss of appetite for food (as a medical condition)”“Loss of appetite, especially as a result of disease”Anorexia ≠ Cachexia
14. In the presence of a tumor, the body mounts an intense inflammatory response associated with anorexia and cachexiaPathophysiology of AnorexiaC. Ezeoke & J. Morley. Pathophysiology of anorexia in the cancer cachexia Syndrome. Journal of Cachexia, Sarcopenia and Muscle 2015; 6: 287–302
15. Causes of Anorexia in Individuals with Cancer• Nausea and vomiting • Early satiety • Taste alterations/sensitivity to food smells • Dry mouth • Constipation/ Diarrhea • Mucositis/stomatitis • Intestinal obstruction• Dysphagia• Anxiety • Depression • Stress (many sources) • Fatigue • MedicationsM. Muscaritoli et al. Prevalence of malnutrition in patients at first medical oncology visit: the PreMiO study. Oncotarget. 2017 Oct 3; 8(45): 79884–79896
16. Symptom Burden a Predictor of Nutritional RiskIsenring E, et al. Nutr Cancer. 2010;62(2):220-228Adapted from Nutrition in Cancer Patients: It Does Make a Difference by Alicia Gilmore, MS, RD, CSO, LD, CNSC Suzanne Dixon, MPH, MS, RD
17. Oncology Dietitian’s RoleBe creativeRely on patience, persistence and repetitionBe advocateInvolve family/caregiversManaging the Challenges of Anorexia
18. Calorie and Protein Needs for Individuals with CancerProtein 0.8 g/kg/day for healthy individuals 1.2 to 2 g/kg/day for catabolic individuals1.5 g/kg/day for those who are metabolically stressedFor cancer patients in general, 1.0 to 1.5 g/kg/day of actual weight (1.2 to 1.5 g/kg/day serves as a target range to maintain or restore lean body mass)Calories25-30 kcals/ kg/day *if resting energy expenditure (REE) and/or total energy expenditure can’t be measured directly*Direct calorimetry, indirect calorimetry, and prediction equations attempt to mirror actual expenditures and account for changes in metabolic state *Predictive equations are dependent on individual’s status—healthy, acutely ill, critically ill, or obese Nutrition Therapy for Adults Receiving Radiation Treatment By Julie Lansford, MPH, RDN, CSO, LDN https://www.todaysdietitian.com/newarchives/0519p44.shtml
19. Cachexia Defined“The presence of significant weight loss or sarcopenia in the absence of simple starvation. “A progressive wasting syndrome characterized by weakness and a marked and progressive loss of body weight, fat, and muscle. Tumor-related factors prevent maintenance of fat and muscle” - Weight loss >5% over the past 6 months; or- Body mass index <20 and degree of weight loss >2%; or- Sarcopenia and any degree of weight loss >2%Sarcopenia = Severe muscle depletionhttps://www.cancer.gov/about-cancer/treatment/side-effects/appetite-loss/nutrition-hp-pdq#_30 Cachexia ≠ Anorexia
20. Physiology of CachexiaDeranged metabolic state, with abnormal hormonal environment Typically occurs in conjunction with anorexia, but not always Pathophysiology hinders nutritional repletion Protein and calories alone will not improve nutritional statusA. Duval et al. mTOR and Tumor Cachexia. Int. J. Mol. Sci. 2018, 19, 2225; doi:10.3390/ijms19082225
21. Hallmarks of Cachexia Insulin resistanceHyperglucagonemia Hyperglycemia Hyperlipidemia Failure to utilize glucose and free fatty acids for energy metabolism due to white fat to brown fat conversion Lean body mass becomes primary energy sourceFearon KCH, et al. Cancer Cachexia: Mediators, Signaling, and Metabolic Pathways. Cell Metab 2012; 16(2): 153-166 Petruzzelli M, et al. A switch from white to brown fat increases energy expenditure in cancer-associated cachexia. Cell Metab. 2014;20(3):433-47. Adapted from Nutrition in Cancer Patients: It Does Make a Difference by Alicia Gilmore, MS, RD, CSO, LD, CNSC Suzanne Dixon, MPH, MS, RD
22. POLLTrue/ FalseAnorexia is defined as a loss of appetite and inability to eat. The term is interchangeable with cachexia.
23. Anorexia and cachexia, can lead to progressive loss of skeletal muscle mass (with or without loss of fat mass) and worsen impairment of function.C. Ezeoke & J. Morley. Pathophysiology of anorexia in the cancer cachexia Syndrome. Journal of Cachexia, Sarcopenia and Muscle 2015; 6: 287–302Sarcopenia
24. Lean Body Mass (LMB)LBM = Everything but fat LBM used for energy depletes skeletal and smooth muscle, organs, skin and mucous membranes, red and white blood cells, connective tissue, platelets and plasma, and more Outcome = MorbidityBosy-Westphal A, Müller MJ. Identification of skeletal muscle mass depletion across age and BMI groups in health and disease -There is need for a unified definition. Int J Obes 39, 379–386(2015)
25. Lean Body Mass Depletion: Predictor of Survival Overweight & obese patients had similar LBM as patients categorized as cachectic Regardless of baseline BMI, weight & muscle loss = survivalTwo prognostic models of survival in lung & GI patients (n=1,473) - Conventional covariates: tumor type, stage, age, performance - Nutrition covariates: BMI, weight loss, muscle index/attenuationMartin L, et al. Cancer cachexia in the age of obesity: skeletal muscle depletion is a powerful prognostic factor, independent of body mass index. J Clin Oncol. 2013;31(12):1539-47. Adapted from Nutrition in Cancer Patients: It Does Make a Difference by Alicia Gilmore, MS, RD, CSO, LD, CNSC Suzanne Dixon, MPH, MS, RD
26. Unintentional Weight LossReality of Unintentional Weight Loss Well-designed study of 17 head and neck patients in active, concurrent therapy protocol DEXA, Indirect Calorimetry, Physical Performance Assessment, Fasting Blood Measures, Serial 24-Hour Dietary Recalls Over 9 Week Follow Up Through Treatment: Weight loss began immediatelyAverage total loss of 6.8 kg (15 lbs) ~ 1.7 lbs per weekLBM accounted for 71% of loss Induced by combination of calorie deficit and underlying inflammatory response, and the switch from LBM and fat for energy to predominantly fat does not occurSilver HJ, et al. Changes in body mass, energy balance, physical function, and inflammatory state in patients with locally advanced head and neck cancer treated with concurrent chemoradiation after low-dose induction chemotherapy. Head Neck. 2007;29(10):893-900
27. Dietary InterventionsOn-going Coaching, Encouragement, Advocate Taste /SmellPresentationAtmosphere Meal preparationFractional intake- meal frequency and snacksFamily dynamics Honor patient’s preferences Nutritional supplementsEnteral nutrition A. Tuca et al. / Critical Reviews in Oncology/Hematology 88 (2013) 625–636
28. Nutrition Intervention Nutritional counseling (diamonds) can increase intakes and improve outcomes better than protein supplements (squares) or no intervention (triangles).Ravasco et al. Head and Neck 27:659-668, 2005.Ravasco et al. J Clin Oncol 23:1431-1438, 2005.
29. Nutrition Intervention Nutritional counseling (diamonds) can increase intakes and improve outcomes better than protein supplements (squares) or no intervention (triangles).Ravasco et al. Head and Neck 27:659-668, 2005.Ravasco et al. J Clin Oncol 23:1431-1438, 2005.
30. Non-Dietary InterventionsFirst address contributory factors: anxiety, depression, family and spiritual distress, malabsorption, pain, oral complications, constipation, insomnia, correctable hormonal factors (thyroid, hypogonadism, adrenal insufficiency, etc), lack of support/help Progestational agents and corticosteroidsCannabinoids – medical cannabis appears more effective than pharmaceuticals; consult knowledgeable resourceProkinetic agents and Proton pump inhibitorsNon-steroidal anti-inflammatory agents Nutrients – omega-3s, amino acids, zinc, vitamins (IV and oral) Exercise – almost always underutilized A. Tuca et al. / Critical Reviews in Oncology/Hematology 88 (2013) 625–636
31. POLLDietary interventions for anorexia and cachexia that help put a brake on unintentional weight loss include:A. Eating Small frequent meals and snacksB. Managing taste changesC. Use of nutritional supplementsD. All of the above
32. Validated Screening ToolsPatient Generated Subjective Global Assessment (PG-SGA) Malnutrition Screening Tool (MST) Malnutrition Screening Tool for Cancer Patients (MSTC) Malnutrition Universal Screening Tool (MUST)• Valid • Specific • Quick and easy to use
33. Screening for Malnutrition RiskScreening ToolItems EvaluatedPopulations ValidatedComponentsPG-SGA7Inpatient and OutpatientConducted by patient and RN Includes diagnosis and physical examMST2Inpatient and OutpatientWeight lossHow much weight lossIs patient is eating less d/t poor appetite MSTC4Inpatient Change in intakeWeight loss Body mass index Eastern Cooperative Oncology Group (ECOG) performance measureMUST4Inpatient BMIUnintentional weight lossAcute disease effect Potential for no oral intake Presence of obesity is noted
34. Nutrition MattersLoss of just 5% of baseline weight can shorten survival Intervening early allows repletion when metabolic changes are not working against you Allowing patients to lose nutritional reserves early leads to death from malnutrition before death from disease processIt is estimated that the deaths of 10-20% of patients with cancer can be attributed to malnutrition rather than to the malignancy itself.Consider Days/Weeks/Months For Nutritional ApproachJ. Arends et al. (2017) ESPEN expert group recommendations for action against cancer related malnutrition. Clin. Nutr. 36, 1187-1196
35. Screening and early nutrition intervention are vital components of patient care
36. POLLTrue/ FalseThe Malnutrition Screening Tool (MST) has been shown to be a valid and reliable for identifying malnutrition risk in adult oncology patients in the ambulatory/outpatient
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